The experiences of person-centred counsellors working with suicidal clients online through the medium of text

ABSTRACT

In this study, we attempt to provide an understanding of the experiences of four UK-based person-centred counsellors working with suicidal clients online using text-based therapies and the impact of their clients’ suicidal ideation upon their “way of being”. The counsellors were selected purposively; each was working as a person-centred counsellor online, was encountering suicidal ideation in their clients, and was a member of a professional organisation. A narrative approach was taken, using unstructured interviews and a stanza format of representation. We found that participants had developed a way of being online that may be distinct from their in-person practice. Challenges included being more directive, lacking physical presence, lacking confidence in assessing risk and questions about empathic understanding. Working online with risk raises specific challenges for person-centred practitioners in line with what is indicated in the little relevant research currently already available.     

A solution-focused approach to working with clients who are suicidal

Self-harm and suicide are amongst the most challenging and frightening problems that therapists and counsellors can encounter in the course of their work. The risk of clients harming themselves in the course of treatment can debilitate the therapists from acting creatively and collaboratively, and make their actions defensive, focused solely on risk assessment rather than therapeutic change.Yet it is precisely a creative and collaborative response, such as that engendered by solution-focused therapy and other models, that is the most likely to facilitate change and re-empower clients to take back charge of their lives. This article describes a solution-focused approach to working with suicidal clients that can be used in conjunction with traditional approaches and which focus on establishing safety as well as assessing risk.Working from this model the clinician shifts to identifying client strengths and coping skills, to collaborating with the client to establish meaningful goals and to helping the client envision a positive future. Arguably, such an approach can increase collaboration between therapist and client and lead to a more client-centred safety plan.     

Counsellors' experiences of working with suicidal clients: An exploratory study

Counselling is increasingly available in a wide variety of contexts, including mental health and psychiatric services. As a consequence, counsellors increasingly work with clients who present with suicidal ideation, expressing either suicidal thought and/or intent in the counselling session. This paper describes an exploratory study that examined the experience of counsellors when working with suicidal clients. The paper considers counsellors' behavioural, cognitive and emotional responses to such suicidal expression, both on a personal and professional level. The research employed semi‐structured interviews. A constant comparative method was used in analysing the transcribed interview text. Results suggest that counsellors experience a range of responses when their clients express suicidal thought, including fear, anxiety, anger and professional impotence. The interviewees also expressed self‐doubts about their professional competence. In addition, they identified the threat of litigation for negligent practice and the lack of confidence in appropriate risk assessment approaches as significant causes for concern. The implications for further research, and practice, are discussed.     

Triangulation or strangulation: managing the suicidal patient

The suicidal person is tortured by an internal dilemma to do with unbearable feelings of separation and loss which seem to be insoluble. The suicidal act is an attempt to resolve this by creating a phantasy in which the intolerable pain associated with a grievance is projected and obliterated by murdering the body that has become identified with it. This type of assault on the self reveals a major confusion between mind and body, affecting the capacity to think and resulting in two-dimensional, rather than three-dimensional, thinking, which can permeate therapeutic efforts, at both individual and systemic levels, in the way these patients are managed by their carers. It is suggested that a safety-net made up of mindful carers, based on a triangular principle, can provide a symbolic or mental space, and a containment for the patient's intolerable states of mind, which can be analogous to an ego-function that is lacking internally, and works well if the net can manage to function as a healthy parental couple. Two case studies are presented as an attempt to illuminate some of the dynamics and difficulties in maintaining the safety-net.     

Outpatient standards of care and the suicidal patient.

This article is a review of the legal and clinical literature on standards of care for nonhospitalized adult suicidal patients. The authors discuss effective assessment, management and treatment procedures that balance the need for high-quality care by a reasonable and prudent practitioner with the requirements of court-determined and statutory standards. Through a review of malpractice claims data and through an examination of the clinical literature we detail the essential guidelines for sound assessment, intervention, and management procedures. The authors specifically discuss common failure situations in outpatient care (e.g., problems in pharmacotherapy, the decision to hospitalize, inappropriate and dual relationships, the assessment of imminence and lethality, and so on). Details regarding practical considerations in developing an outpatient standard of care are provided, as are suggestions that such a standard of care must include an ongoing assessment of the therapeutic alliance.     

Suicide and internalised relationships: A study from the perspective of psychotherapists working with suicidal patients

A study was conducted into the personal meanings of suicide. It is recognised that early experiences of relationships can have a bearing upon a later tendency towards suicide. This project investigated the representations which these relationships take on within the person's inner world and their effect upon the person's behaviour. One hundred psychotherapists were surveyed, by means of a postal questionnaire, regarding their work with suicidal patients. Five follow-up interviews were conducted. The main themes that emerged in the patients' relationships were rejection, invasion and engulfment. These were experienced as forms of abandonment. Incidents involving loss or rejection in the patients' present life were found to re-activate these earlier relationships.     

Introduction to the special issue on visual working memory

Visual working memory is a volatile, limited-capacity memory that appears to play an important role in our impression of a visual world that is continuous in time. It also mediates between the contents of the mind and the contents of that visual world. Research on visual working memory has become increasingly prominent in recent years. The articles in this special issue of Attention, Perception, & Psychophysics describe new empirical findings and theoretical understandings of the topic.     

Conceptions of ethical competence in relation to action readiness in Education for Sustainable Development

This paper explores notions of ethical competence in relation to Education for Sustainable Development (ESD). It carves out a conceptual field for future empirical research, by coupling the promotion of action readiness as an empirical concept with a theoretical understanding of ethical competence. The concept of competence displays interpretative pluralism as a concrete attribute of an individual or task and an unattainable ideal beyond the specific. With interpretive care, ethical competence, with its origin in values education, is suggested as a foundation of action readiness as ESD competence. In educational practice, action readiness is assumed to be fostered through real-world learning opportunities.     

Perceived corporate ethical values and individual cynicism of working students

This study explored a proposed relationship between the corporate ethical values and cynicism of 195 working students. Analysis indicated students' perceived ethical values were negatively related to individual cynicism after accounting for several variables.     

Impact upon therapy and the therapist when working with suicidal patients: some transference and countertransference aspects

The suicide, or attempted suicide, of a client/patient is something that a substantial number of counsellors and psychotherapists have encountered during their career. The literature indicates that this can be a cause of anxiety for many. In this paper the experience of psychotherapists working with suicidal patients is explored. One hundred psychotherapists were surveyed, by means of a postal questionnaire. Five follow-up interviews were conducted. The findings indicate that suicidal patients can evoke intense feelings within the therapist, and the meanings of this are discussed. The links with the concept of projective identification are particularly considered. It is noted how such feelings, experienced within the transference relationship and the therapist's own countertransference, can reflect the inner world of the patient concerned. The psychotherapists described how they felt themselves to have been affected by the work, both personally and professionally. Commonly mentioned responses included feelings of hopelessness and helplessness and a sense of failure. Finally, the respondents outlined measures that they believed to be vital for their own support. The importance of firm boundaries and staying in the therapeutic role is discussed.     

The study of suicidal behavior in the schools

The studies reviewed indicate that suicidal behavior is infrequent among school children (12%), but increases progressively among junior high (35%), high school (65%), and college students (50-65%). Though considerable, these values are lower than those of similar-age psychiatric populations. Estimates of the rate of actual attempts were 3% for elementary students, 11% for high school students, and 15-18% for college students. Most were low-lethality attempts for which medical or other attention was not sought. Accordingly, the vast majority of suicide attempts will not be uncovered by investigations dealing solely with clinical or medically identified populations. The most commonly identified correlates of suicidal behaviors included depressive symptoms, social problems, family disorganization and problems, life stress, and poor problem-solving skills. Academic problems were not as important. These findings must be interpreted in light of methodological constraints. Response rates have been low, samples have been small, minorities have been underrepresented, nonstudents have been ignored, and volunteers of unreported characteristics have predominated. The representativeness of such groups is questionable. The definition and categorization of behaviors have varied considerably, making between-study comparisons difficult. The differences among thoughts, threats, and attempts (the most frequently used categories) have often not been taken into account. Rather, in analyses, these behaviors have been treated as if they were homogeneous entities and grouped together. Where attempters have been separated from ideators, they too have been treated as a single entity. Many deliberately survived attempts are manipulative and oriented toward the benefits the individual survivors expect. Such attempts probably differ substantially in nature from those attempts where survival is not intended. Understanding of this phenomenon could be enhanced by a comparison of the characteristics of those with high- and low-lethality attempts. Similarly, a third group of behaviors--that of chronic behavior patterns that potentially hasten death (alcoholism, drug abuse, self-mutilation, and risk taking)--has not been adequately addressed in terms of its relationship to more discrete suicidal events. Data have generally been obtained via anonymous self-administered questionnaires. The accuracy of retrospective self-reports on emotionally laden events is suspect. Only in two instances have self-reported questionnaire data been validated via interviews with subjects alone or subjects and their families. The time frames on which the referent behaviors has been collected have included "last week", "last month", "last year", "lifetime", and not specified. The longer the interval between the occurrence of the behavior and the report, the greater the likelihood that some reporting inaccuracies may occur.(ABSTRACT TRUNCATED AT 400 WORDS)     

Children with AIDS in the public schools: The ethical issues

The question of whether to allow children with AIDS to attend public school generates explosive emotions and has wide-reaching consequences. This paper focuses on the perspective of parents of well children who may be asked to attend school with children who have AIDS. These parents are poised at the heart of the dilemma: they are the ethical “bottom line,” and an argument that fails to satisfy them ought not to satisfy anyone. The conflicting commitments these parents face are first to the parentchild covenant which requires them to act in their child's best interests, and second, to the principles of beneficence and justice, which require them not to further burden a sick child with ostracism and isolation. Almost exact parallels exist between this issue and that of proxy consent by parents for children's participation in low-risk, non-therapeutic research. The lengthy and important debate between Paul Ramsey and Richard McCormick on this question is analyzed, concluding that McCormick's position in favor of thoughtful proxy consent is the more compelling. Returning to the question of allowing children with AIDS to attend school, the essay shows why the parallels are persuasive. On the ethical level, the apparent conflict of obligations is almost exactly the same; on the pragmatic level, the essay shows why sharing a classroom with a child who has AIDS is comparable to the “low-risk” category that the National Commission for the Protection of Human Subjects found acceptable in its 1978 guidelines. The essay concludes that parents of healthy childrenmay and ought to accept the presence of children with AIDS in the public school.     

The study of suicidal lives

Thirty suicides about whom book-length biographies have been written were examined in the framework of the ten statements formulated by Leenaars for each of his ten theories of suicide. Suicides who fit well with particular theories were identified, and the theories compared both for their success in describing the suicides and for their similarity with one another.     

The psychodynamics of hope in suicidal despair

For suicidal individuals, crushing hopelessness correlates more strongly than depression with suicidal intent. Ambivalence is recognized as a principal aspect of suicidality – wanting to die and wanting to be rescued at the same time. Hope is the mental state in which the desire of a positive outcome in one’s life is directed toward the future, and supports a positive resolution to psychic pain, thereby playing an important role in suicide prevention by delaying self-destructive action. This paper explores the psychodynamics of hope in suicidal distress, as it functions to support the suicidal patient’s sense of connection over abandonment and rescue over the wish to die. Three pathways that instill and support hope in suicidal patients are examined through the use of clinical examples.     

Intentions to select a given level of care when confronted with an ethical issue: the impact of a living will

The aim of this study is to evaluate the level of care nurses intended to select in a potential situation of overly aggressive therapy, whether the patient had or did not have a living will. MANOVA revealed that the presence of a living will had a significant impact on nurses' decision making when selecting a level of care ( p < .0001); this impact was noted for each construct in the theoretical framework ( p < .005). Multiple regression analysis indicated the 86% of the variance in nurses' intention was determined by the cognitive component of their attitude and perceived professional norm ( p < .0001). In summary, most of the nurses intended to respect the wishes expressed by the patient in a living will.     

Flexible representations in visual working memory and interactions with long‐term learning: Commentary on the special issue

This special issue of the British Journal of Psychology brings together cutting edge research on a range of topics in visual working memory (VWM). In this commentary, we attempt to summarize common themes in current VWM research exemplified in this issue. The articles include several reviews of important topics as well as empirical papers covering three main themes. The first concerns the nature of mental representations of memoranda in the commonly used delayed estimation task, where both fine‐grained and broad categorical details appear to be represented, and their susceptibility to interference. The second concerns interactions between VWM representations, both those that produce individuation of representations and those that create an overarching ensemble structure. Finally, the third main topic concerns the use of VWM during visual search and in the learning of repeated configurations in search displays. The work presented here, and other work in the field, points to a rich interplay between representations in VWM but also between VWM and information in long‐term memory. Opportunities for further investigation are highlighted throughout.     

The material culture of suicidal fantasies

In this study, the author examined the content of impulsive suicidal fantasies among U.S. undergraduates. Of 546 participants, 45.6% reported incidents in which they fantasized about killing themselves. Most fantasies (95%) included explicit references to suicide methods, and most of those fantasies (98%) involved human-made tools or materials (e.g., drugs, cutlery, firearms). The methods reported in most suicidal fantasies seem to have been suggested by the mass media. The findings suggest that suicidal thoughts do not occur without explicit and detailed information about suicide methods involving material culture.